Tuesday, June 25, 2013

The Interagency Pain Research Coordinating Committee (IPRCC) is a federal advisory committee created by the Department of Health and Human Services to enhance pain research efforts and promote collaboration across the government, with the ultimate goals of advancing fundamental understanding of pain and improving pain-related treatment strategies. The Committee roster will include seven Federal members and twelve non-Federal members, six drawn from the scientific and medical communities and six members of the public and stakeholder groups. The Department of Health and Human Services Secretary will review the necessity of the Committee at least once every 2 years.

As specified in Section 4305(b) of the Public Law 111-148 ("Affordable Care Act (ACA)") the Committee has been asked to:

Develop a summary of advances in pain care research supported or conducted by the Federal agencies relevant to the diagnosis, prevention, and treatment of pain and diseases and disorders associated with pain.

Identify critical gaps in basic and clinical research on the symptoms and causes of pain.

Make recommendations to ensure that the activities of the National Institutes of Health and other Federal agencies are free of unnecessary duplication of effort.

Make recommendations on how best to disseminate information on pain care.

Make recommendations on how to expand partnerships between public entities and private entities to expand collaborative, cross-cutting research.

The NIH Pain Consortium was established to enhance pain research and promote collaboration among researchers across the many NIH Institutes and Centers that have programs and activities addressing pain. To this end, the following goals have been identified for the Pain Consortium:

To develop a comprehensive and forward-thinking pain research agenda for the NIH - one that builds on what we have learned from our past efforts.

To identify key opportunities in pain research, particularly those that provide for multidisciplinary and trans-NIH participation.

To increase visibility for pain research - both within the NIH intramural and extramural communities, as well as outside the NIH. The latter audiences include our various pain advocacy and patient groups who have expressed their interests through scientific and legislative channels.

To pursue the pain research agenda through Public-Private partnerships, wherever applicable. This underscores a key dynamic that has been reinforced and encouraged through the Roadmap process.

Sunday, June 23, 2013

The use of narcotic painkillers, or opioids, has boomed over the past decade as drug makers and doctors have promoted them for a new use: treating long-term pain from back injuries, headaches, arthritisand conditions like fibromyalgia. Insurers have also grown to see pills as a cheaper way to treat chronic pain than other methods.MultimediaSome patients are greatly helped by opioids, a large family of medications. Among the more widely used opioids are oxycodone, which is found in Percocet and OxyContin, and hydrocodone, which is used in Vicodin. Other potent opioids include fentanyl and methadone. Narcotic painkillers are now the most widely prescribed class of medications in the United States, and prescriptions for the strongest opioids, including OxyContin, have increased nearly fourfold over the past decade.

There is increasing evidence, however, that such drugs, along with being widely abused, are often ineffective in treating long-term pain and can have serious consequences, particularly when used in high doses. Along with the risk of addiction, side effects can include psychological dependence, reduced drive, extreme lethargy and sleep apnea.

The economic costs associated with the painkiller boom have also proved enormous, giving rise to a host of unanticipated medical, legal and social costs. Over the past decade, the legal — and illegal — use of these drugs has given birth to new businesses and expanded existing ones. These include urine-screening tests to make sure patients are taking the drugs properly, added sales of addiction treatment drugs, growing emergency-room expenses, law-enforcement budgets and skyrocketing costs for insurers.

In the short run, treating a patient with an opioid like OxyContin, which costs about $6,000 a year, is less expensive than putting a patient through a pain-treatment program that emphasizes physical therapy and behavior modification. But over time, such programs, which run from $15,000 to $25,000, might yield far lower costs.

OBJECTIVE.: Recent surveys suggest more than one third of patients utilize the Internet to seek information about chronic pain (CP) and that 60% of patients feel more confident in the information provided online than provided by their physician. Unfortunately, the quality of online information is questionable. For example, some Websites make unsubstantiated claims while others may have covert motives (i.e., product advertisement). This article presents two studies that utilized a well-validated tool to evaluate the quality of online CP-related information.

DESIGN.: A Website search was conducted by entering the most commonly used pain-related search terms into the three most commonly used search engines in North America. In study 1, the first 50 Websites from each search were evaluated using a consumer-focused evaluation tool-the DISCERN. In study 2, 21 clients with CP used the DISCERN to rate a random selection of Websites from among the 10 highest scoring and five lower scoring sites from Study 1, and answered open-ended questions regarding the DISCERN and Websites.

RESULTS.: Ratings indicated that Websites ranged substantially in quality, with many providing incomplete and incorrect information, and others providing accurate and detailed information. The majority of the Websites provided low-quality information. Client ratings of the Websites were consistent with those of the researchers.

CONCLUSIONS.: Overall, these findings speak to the risks associated with clients making CP-related treatment choices based on information obtained online without first evaluating the Website.

Although doctors sometimes prescribe anti-seizure drugs to treat chronic pain in the vulva, just a handful of low-quality studies have examined the drugs' effects, according to a new review.

Based on these studies, "it's very difficult to make definitive statements on efficacy," said Dr. Raphael Leo, the study's author from the State University of New York at Buffalo. "Certainly, more investigation is warranted."

Still, "I think that there is promise" for the use of anti-seizure medications, he added.

Chronic pain in a woman's genitals, also called vulvodynia, affects as many as one in 12 women (see Reuters Health report of Sept 23, 2011 here: reut.rs/oeJRax).

The underlying cause of the pain is not always known, so doctors often try a variety of treatment approaches to see what will work.

Those include topical creams to reduce pain, physical therapy, antidepressants and - in extreme cases - surgery to remove the painful tissue.

Anti-seizure medications, such as gabapentin (marketed as Neurontin), are also used to treat vulvodynia. One survey found up to two-thirds of doctors prescribe gabapentin for the condition.

"Unfortunately, there hasn't been much systematic investigation of an appropriate means of treatment," Leo told Reuters Health.

To see whether research supports the use of anti-seizure drugs, he collected the results of all studies testing these medications on women with the pain disorder.

He found nine reports, none of which met the criteria for a high-quality clinical trial.

In a "gold standard" medical trial, women would be randomly assigned to take the medicine or a drug-free placebo, with neither women nor the researchers knowing which pill each person was taking. This is called a double-blind, randomized controlled trial.

Instead, the studies Leo found used less rigorous research designs, including "open label" formats, where patients and doctors know which drug each participant is taking. He also found descriptions of people taking anti-seizure medications and reviews of patients' medical charts.

The medications studied included gabapentin, pregabalin, lamotrigine and carbamazepine, Leo wrote in The Journal of Sexual Medicine.

All of the studies showed that some women reported improvements in their symptoms after taking an anti-seizure drug.

For instance, one study that reviewed the medical charts of 147 women taking gabapentin found that symptoms completely went away in 67 percent of patients. Most of the other patients showed no response.

"Definitely the open label studies have been encouraging," said Dr. Samantha Meltzer-Brody, director of the perinatal psychiatry program at the University of North Carolina Center for Women's Mood Disorders.

"This may be a very useful treatment for some women, but until there are the gold standard, double-blind studies, there is a need for further scientific investigation," said Meltzer-Brody, whose study on lamotrigine was included in Leo's review.

Without high-quality clinical trials, doctors can't say for certain whether the drug is any better than a placebo, nor whether women would have had an improvement in symptoms on their own, without medication.

"Any sort of conclusions one draws from such non-experimental studies are quite limited," said Leo.

He said more research is needed on treatments for vulvodynia.

Until then, "we don't understand whether one should consider one particular form of therapy over another and who would respond best to what type of treatment."

Friday, June 14, 2013

The emerging recognition that many patients develop chronic pain after surgery has spurred a host of behavioral and anatomic research.

So far, these studies have yet to produce any breakthroughs in the understanding, and more importantly for patients, the treatment of the problem. But during a session at the 2012 annual meeting of the American Society of Anesthesiologists, experts said the question was not whether, but when, those treatments would arrive.

"Not surprisingly, chronic postsurgical pain has become a popular topic," said Timothy Brennan, MD, PhD, the Samir Gergis Professor and Vice Chair for Research at the University of Iowa's Roy J. and Lucile A. Carver School of Medicine, in Iowa City. "Compared with a patient who develops an injury after a car accident, with surgical patients we know when our patients are going to get injured, and we know what type of injury is going to occur: the surgery. So, I think our goal will be to study surgical patients and evaluate their pain responses when they don't have this premeditated injury, then follow them through the postoperative period in the hope that we can learn to predict chronic postsurgical pain and the factors related to its development."

Several studies have associated the development of chronic postsurgical pain and other unfavorable long-term outcomes with somatic and psychological predictors. A 2007 Dutch investigation (Ann Surg 2007;245:487-494) in 625 patients, for example, found that psychological factors such as fear of long-term consequences and lack of optimism were predictors of persistent pain, disability and low quality of life after surgery.

"I think, sometimes, functional limitations and lower quality of life may impact a patient's perception of their pain and certainly the development of persistent pain afterward," Dr. Brennan noted. "This reminds us that there are many psychological factors associated with the development of persistent pain."

More recently, a team of Norwegian researchers followed more than 12,000 patients, 2,043 of whom had undergone surgery within three months of the start of the study (Pain2012;153:1390-1396). Persistent pain in the area of surgery was reported by 40.4% of the patients. The researchers also found strong associations between sensory abnormalities and persistent pain. "Broad studies such as these cast a wide net, and are certainly continuing to point to this relevant problem of disability after surgery and significant pain reports," Dr. Brennan said.

Few studies, however, have shed as much light on the anatomic changes that occur in response to pain as a longitudinal investigation by Baliki and colleagues, reported last year inNature Neuroscience (2012;15:1117-1119), to determine the mechanism of brain reorganization as pain moves from acute to chronic.

The researchers followed patients with subacute back pain for more than a year, stratifying them into those whose pain did not resolve and those whose pain improved, and also compared them with a group of healthy controls. Patients whose pain persisted showed decreases in the density of gray matter in the brain.

"The researchers also looked at the connectivity between various parts of the pain network and what I call the emotional network," Dr. Brennan said. They found that an initially greater level of connectivity between a section of the brain called the nucleus accumbens, which is critical to the sensation of pleasure, and the prefrontal cortex predicted pain persistence. This increased connectivity, they inferred, suggests that corticostriatal circuitry is causally involved in the transition from acute to chronic pain.

"The medial prefrontal cortex is one of those areas in the brain that signals the affective component of pain," Dr. Brennan explained. "When pain is well connected to the nucleus accumbens, pain pathways are strongly linked to psychological pathways. This link was found to be an accurate predictor of the transition from subacute to chronic pain. Now, whether or not this applies to a perioperative situation certainly remains to be seen," he continued. "We know that there are similarities between back pain patients and postsurgical patients, but more research needs to be performed."

For clinicians, of course, the physiology of how postoperative pain becomes chronic is most important if it leads to ways of preventing the transformation. "The literature suggests it may not be that easy," Dr. Brennan said.

Eugene R. Viscusi, MD, professor of anesthesiology and director of acute pain management at Thomas Jefferson University, in Philadelphia, noted that the magnitude of chronic postsurgical pain is vastly underestimated by most anesthesiologists and surgeons.

"I agree with Dr. Brennan that a link with severe acute pain alone is probably too simplistic," said Dr. Viscusi, a member of the editorial board of Anesthesiology News. "My opinion is that since the causes are likely multifactorial, there will not be a single solution. What's more, some patients may just have an inherent risk. Nevertheless, several interesting studies support that preoperative and postoperative pregabalin [Lyrica, Pfizer] and ketamine may reduce longer-term pain after surgery. The best current evidence suggests that a multimodal analgesic approach and adjustment of surgical technique may make a difference."